Mail To:



Mail To:

SC Department of Veterans’ Affairs

ATTN: SCMFRF Coordinator

1205 Pendleton Street, Ste. 369

Columbia, SC 29201

SOUTH CAROLINA MILITARY FAMILY RELIEF FUND (SCMFRF) APPLICATION

If you need assistance completing the application please call 803.734.0200.

MILITARY MEMBER’S INFORMATION

NAME: _________________________________________________ BIRTHDATE:

HOME ADDRESS: _____________________________________________________ ___________________

CITY: _________________________ STATE: ZIP:

HOME PHONE: _______________________________________________________________________

BRANCH: ________ ________ RANK/PAY GRADE: ____________ SOCIAL SECURITY #:_________________

HOME STATION UNIT OF ASSIGNMENT: ___________________________________________________

(Where you would normally drill when not on active duty.)

EMAIL ADDRESS: ______________________________________________________________________

APPLICANT’S INFORMATION (IF OTHER THAN MILITARY MEMBER)

NAME: __________________________________________________ SSN: _____________________________

HOME ADDRESS: ___________________________________________________________________________

CITY: _________________________ STATE: ZIP:

PHONE: ________________ RELATIONSHIP TO MILITARY MEMBER: ________________________________

MILITARY UNIT POINT OF CONTACT FOR VERIFICATION OF THE ABOVE INFORMATION:

NAME: ____________________________________________________________________________________

POSITION/TITLE: _______________________________ PHONE NUMBER: ____________________________

CHECK TYPE(S) OF GRANT(S) REQUESTED:

STATUS BASED GRANT -- FLAT RATE OF $500

▪ Members who are unmarried or have no family members enrolled in DEERS are ineligible.

▪ Service member must provide proof that family member are enrolled in DEERS.

▪ Rank must be no higher than O-3 or W-2 (based upon rank at time of mobilization).

▪ Orders must state one of the following:

o Operation Noble Eagle/Enduring Freedom/Iraqi Freedom

o Executive Order #13223

o Any future operations as determined by the President or Governor of South Carolina.

▪ Service member was/is on active military duty for 30 consecutive days.

▪ May receive a grant only one time in each fiscal year and only one time for each active duty order.

▪ Application must be signed.

SIGNATURE OF APPLICANT: ______________________________________ DATE: ____________________

SCMFRF FORM 1 – SEP 2013 PAGE 1 of 3

COMPLETE THIS PAGE ONLY IF APPLYING FOR CASUALTY BASED OR NEED BASED

GRANT - CHECK TYPE(S) OF GRANT(S) REQUESTED:

CASUALTY BASED GRANT -- FLAT RATE OF $1,000

▪ Must include all rules listed in Status Based Grant.

▪ Service member must submit documentation stating that they sustained a service-connected injury or illness.

▪ Member’s next of kin must submit a statement that the member was KIA, MIA or is a POW.

▪ The requirement of 30 consecutive days or more of active military duty may be waived by the department upon receipt of written request indicating the circumstances justifying the waiver.

▪ Grant may be received only one time for each active duty order.

NEED BASED GRANT -- UP TO $2,000

▪ Must include all rules listed in Status Based Grant.

▪ Members who are unmarried or have no family members enrolled in DEERS are ineligible.

▪ Must submit monthly civilian AND military pay stub to show the service member sustained a 30% or

greater decrease from his or her civilian salary.

▪ Must submit proof of expenses or bills.

▪ Must submit a signed statement on what the grant will be used for.

▪ This grant will only pay the amount of bills attached to this application up to the amount of $2,000.

▪ If custodial parent or guardian is applying on behalf of a member’s dependent, then proof of guardianship must be provided.

▪ No additional applications may be accepted within 180 days from receipt of any prior applications.

(ONLY COMPLETE THIS SECTION IF APPLYING FOR NEED BASED GRANT)

1. Monthly Civilian Salary includes NO overtime (attach copy of pay stub): $_______________________

2. Monthly Military Salary include base pay and BAH (attach copy of pay stub): $_______________________

3. Is military salary at least 30% less than civilian salary? YES NO

(If you do NOT meet the 30% requirement, you will NOT qualify for the Need-Based Grant)

EXPENSE AMOUNT DESCRIBE ATTACHMENT(S)

Food/clothing: $________________ _____________________________

Rent/mortgage: $________________ ________________________________

Major Home Appliances: $________________ ________________________________

Utilities: $________________ ________________________________

Medical services/prescriptions: $________________ ________________________________

Insurance: $________________ ________________________________

Vehicle payments: $________________ ________________________________

_________________________________________________ ________________________________

SIGNATURE OF APPLICANT DATE

I certify the above information to be true and correct. I authorize verification/release of the information I am providing on this application. I authorize the State of South Carolina and the South Carolina Department of Veterans’ Affairs access to my pertinent records, including information maintained in DEERS, as necessary to evaluate my application. Disclosure of information on this form, including social security numbers, is voluntary. Failure to provide the requested information, however, will prohibit the processing of this grant application. In accordance with applicable laws, the State of South Carolina and the South Carolina Department of Veterans’ Affairs will maintain confidentiality regarding the application and any grant given or denied, except as required to process this or subsequent applications, or as otherwise required by law.

SCMFRF FORM 1 – SEP 2013 PAGE 2 of 3

Checklist of Documentation Required

Documentation required for the Casualty Based Grant:

• Original application – signed and dated

• Copy of DD Form 214 (if currently on orders, then a copy of your orders)

• Signed statement indicating member has sustained service-connected injury/illness (tell a little bit about what happened)

• Documentation from DoD stating member was wounded (or ill) (could be LOD or DA Form 2173)

• Documentation from USDVA or DoD Substantiating service connected illness/injury (copy of awards/rating letter if disability claim filed with VA)

Documentation required for the Need Based Grant:

• Original application – signed and dated

• Copy of DD Form 214 (if currently on orders, then a copy of your orders)

• Proof of family member enrolled in DEERS

• Signed statement explaining why you are applying for this grant and that, if awarded, grant will be used for said purpose(s)

• Copy of civilian and military pay stubs

• Copies of invoices/bills

SCMFRF FORM 1 – SEP 2013 PAGE 3 of 3

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